The aging physician model
By Larry Kravitz, MD
I had a retirement role model once. A secret role model, who didn’t retire. In the moment, I never told him of my admiration. I was just passing through his clinic, 40 years ago, and never knew how long his impact would remain within me.
As a fourth-year medical student at George Washington University, I had signed up for a tropical medicine elective at the Gorgas Institute in Panama, one of the top infectious disease research institutes in the Western Hemisphere. Gorgas was created in 1921, named for Dr. William Crawford Gorgas, who eradicated yellow fever in Panama, thus facilitating the construction of the Panama Canal. Interspersed with the daily lectures, we rounded in the hospitals and saw florid cases of tetanus, measles, and typhoid. We went on field trips including visiting a leper colony, a living museum of medical history.
I was also invited to join an investigation of an equine encephalitis outbreak (no thank you; I decided I was too young to die as a medical martyr succumbing to the disease I was cataloging). So instead, on most days, I was assigned to the cutaneous leishmaniasis lab. That or the micro lab, looking through slides of poop for hookworms and roundworms. I worked under the world’s top expert in leishmaniasis. He was a thin, quiet 75-year-old man with a delicate touch for scraping sample slides from open, festering skin ulcers. He would teach me how to look under the microscope for trypanosoma cruzi, the parasite from blood-sucking reduviid bugs that dropped on the sleeping Panamanians from the straw roofs of their primitive domiciles. My revered doctor showed up everyday to the clinic, always on time, wearing his bow tie and Panama straw hat. And sometimes after work, I would see him, jogging home, 5 miles, out along the jetty at the western edge of the Panama Canal along the Pacific Ocean, with the waning sun leading his way.
At 25 years of age, I thought, “That’s who I want to be.” I can’t imagine still being able to do all of that at 75, but if I did, that would be a good medical life.
Now I am 65, and have been a practicing family physician for 40 years, and people keep asking if I am going to retire?
My first immersion in physician retirement came when my medical group had to let go of our paper charts and switch to EMR. That culled the herd of my older physician peers. It was the medical version of the movie, “The Purge.” So many of my older colleagues just threw up their arms in horror and screamed, “I’m outta here.” In the Darwinian new changes of medicine, you either adapt or die ... or retire.
In 2014 there were about 78,000 clinically active primary care physicians between ages 55 and 80 years in the United States. The median age of retirement from clinical activity of all primary care physicians who retired in the period from 2010 to 2014 was 64.9 years, but as many as 40 percent of 75-year-old physicians were still practicing in some format. The number of physicians in the U.S. over 65 years of age more than quadrupled between 1975 and 2013.
What of these aging physicians? A 2017 article in BMJ caused controversy in concluding, “Patients treated by older physicians had higher mortality than patients cared for by younger physicians.”
I am an aging teacher of medical students. I used to worry whether I was losing my edge. Was I keeping up? In my advancing years, was I ingraining my own insidious errors in my students’ medical repertoires?
In 2016, a working group within the American Medical Association supported the idea that with age come declining skills: “Comprehensive assessment approaches show that increasing physician age and longer time since graduation predict overall poorer performance.”
But surveys show older physicians have a higher level of job satisfaction, lower sense of stress levels, and lower rates of malpractice claims settlements. Also, age is not the only factor that affects competence and it might not even be the most important one. “Solo practice, international training, lack of board certification, general practice, and incongruence between training and scope of practice predict an increased likelihood of poor outcomes on performance assessments,” the AMA authors noted.
It’s not written in stone that we will be worse physicians when we are older. It’s just another challenge in yet another day. Beware of stagnation. Know that you are at risk for erosion of your skills. Constantly reassess. Constantly adapt and rejuvenate your aging practices, whether you are 35 or 75. And it’s not just knowing the newest pharmaceutical. So much of the real professional recertification is keeping up with technology and bureaucracy: EMR, HIPAA secure texting, streaming CME podcasts (at two times speed if you want mental exercise), macros (and MACRA), Dragon dictation, patient portals, electronic prescribing, POCUS, and ICD-10. Adapting to our realistic world. That’s a form of recertification, and there really is some intellectual stimulation in some of those cursed administrative burdens like the EMR. They really can improve quality of care, despite the price of your documentation burnout.
My personal way to adapt is to teach. To teach is too learn. Now I have made peace with the quality of skills I am sharing. Of course, I am teaching them both the wrong and the right. Becoming a teacher means being imperfect but having the fortitude to stand up in front of the student and be present for their learning as well as your own.
We selected this new generation of medical students to be mature beyond their years. They will embrace our humanity and imperfection. They will embrace my knowledge and accept the risk of my ingrained errors and outdated training. Being a good student means being discriminating about the knowledge you accept. We live both in an Information Age and a Disinformation Age. Our young followers are more facile in processing data than we will ever be. And so I tell them at the start of every rotation, “You are here for two things. To learn things that help you be a better doctor, and to learn what things you never want to be as a doctor. I am sure by the end of the month, I will embody them both.” As long as I continue to step up to the plate and accept them into my world, I will grow as a better doctor alongside them. Keeping students in my practice forces me to keep up to date, and I don’t think I make any more mistakes teaching students now than I did 20 years ago, probably less. Aging has just made me more honest and transparent about the process.
Neuroplasticity is the ability of the brain to change throughout an individual’s life. We know now that the aging brain is not just decaying. Some areas are growing new connections. And we can help our brains learn. We have control over our brain changes. But to quote Somerset Maugham, an author who always speaks to the physician’s heart, “the path to salvation is narrow and as difficult to walk as on a razor’s edge.” There is no retirement from our lives. There is no retirement for our minds. To quote a Nike ad that speaks to my runner’s heart, “there is no finish line.”
My company’s CEO and founder has a role for me now. He says my multispecialty group needs “gray beards.” Those older physicians who mentor and steady the new partners — the young bucks of medicine, with their unbridled healing passions. We watch over them. It doesn’t take much. It’s an immediate collegial pat on the shoulder rather than the looming knuckle rapping of the Peer Review Committee. Peer review is the stick and I am the carrot. The living enticement that they can make it. I’m just an average guy and I’ve made it all these years. So can you.
I look down the office hallway full of toiling young physicians and I feel the value of multigenerational providers. I look over to my young scribe, putting in her gap year before she joins our ranks at medical school. Next to her is the latest iteration of third-year medical student on rotation with me. I teach his awkward fingers to be sensing instruments of liver spans and swollen spleens, and thyroid nodules and knee effusions. I show him how to gently scrape away scaling skin to view fungal hyphae under the microscope.
And as I again walk the two miles home from my clinic, with the evening sun sinking over the Texas llano, I find that I, too, am an iteration, that of my distant Panamanian role model. And I now understand that 40 years ago, I had a role in that role modeling. It dawns on me that the old Panamanian secretly needed me in his life to become the role model to whom I gazed upward. Without a student to regularly rekindle his medical passion, would he have stayed the beacon that he was? As I incorporated all his wizened medical acumen, were my questions quietly piquing a renewal of his research vigor? Does it really take all of us together to create an enlightened milieu that we can all find inspiring? I choose to answer “yes,” and I hope to affirm that even more so when I’ve walked a further 50 years down this medical path.
Justin Bartos said
Thank you Larry for reaffirming what my instincts told me to do. I cannot retire when I have reached such a level of enlightenment so I will continue to share my experience with the generation that follows. My entire career has been spent in transition. I have witnessed the evolution of managed care affecting the delivery system. The marvels of technology and pharmaceuticals. The promise of genetic based therapies for the future. The speed of change continues to accelerate beyond my capacity to digest it. However, my patients still value the care I provide and query me for guidance through a world they struggle to comprehend. The value of this relationship is stronger than ever. I need to share this with the students that follow.
Hugh Wilson Jr said
This is a fine review of our lives as we older physicians look back. Adaptation is key to our continued service in later years. We never escape the fact we are all uncertain at times, but so often we are rewarded by our opportunity to encourage younger physicians in their life journeys. As a lagniappe, they become poised to be our primary care doctors a ways down the years.
Larry Kravitz said
If I may borrow the word, the comments of Dr. Wilson and Dr. Bartos are a lagniappe to my blog. Thank you both.